Analysis Safety Awareness Level In general, fishing is a high-risk occupation, and the traditional attitude of fishers is to accept the risks involved. Even after receiving a warning, individuals tend to search for alternative interpretations that will neutralize the threat conveyed by the message.4 In the instance of the ShannonDawn and the RachelM, although gale warnings had been broadcast, greater emphasis was placed on the milder weather encountered. The threat posed by the forecast was downplayed, even when the weather deteriorated. This may, in part, be attributable to the fishers' perception of risk. Repeated exposure to a perceived risk without any resulting adverse consequences can result in a gradual shift from a heightened state of alertness and readiness to respond to a risk, to a relaxed or normal state. Each successive harmless exposure reduces an individual's attention to the source of risk. In essence, the individual becomes desensitized to the risk, and the given level of risk becomes the norm. Changes in the perception of risk can result in individuals engaging in riskier behaviour. In this occurrence, this is reflected in the fishers continuing to fish in deteriorating weather conditions, without wearing any form of personal life-saving equipment and during the high-risk process of transferring personnel and fish from one vessel to another. While changes in risk perception play a role in the normalization and acceptance of risk, lifejackets the mandated personal life-saving equipment are cumbersome to wear. Lifejackets The swamped/capsized vessel ShannonDawn was located approximately four nautical miles in a south-southwesterly direction from the transfer point. The PFDs recovered were found downwind, ashore on Berens Island near where the RachelM was found. This suggests that, when the two fishers aboard the RachelM transferred with the fish tubs over to the ShannonDawn,they did not transfer the lifejackets/PFDs from one vessel to the other. Safety Equipment Requirement and Safety Statistics indicate that most fishers do not wear personal life-saving equipment when engaged in fishing activity, despite inclement weather. Because lifejackets are cumbersome to wear, fishers do not wear them even in adverse weather conditions. Furthermore, as space on small fishing vessels is often restricted, personal life-saving devices may not be readily available during an emergency. The situation is further compounded by the fact that small vessels are susceptible to sudden movement or sudden capsizing in adverse weather. The shortcomings of the standard lifejacket in Canada's harsh climatic conditions have been highlighted in several investigation reports. To maximize the survival time for a person in the water, all personal life-saving equipment for use in Canadian waters ought to incorporate two key requirements thermal protection and inherent buoyancy. Concerned about the high risk to survival faced by personnel in the cold waters of Canada, the TSB recommended to Transport Canada that small boats be required to carry anti-exposure work suits or immersion suits.5 To date, the life-saving equipment carriage requirements of the Small Fishing Vessel Inspection Regulations have not been changed. Although Transport Canada Marine Safety recognizes the limitations of lifejackets and the importance of the requirement to wear component in determining the most appropriate personal life-saving equipment, this principle is not uniformly applied to the regulatory regime, which continues to call for the carriage of standard lifejackets. The inappropriateness of the personal life-saving equipment and carriage requirement in the current regulatory regime places fishers at undue risk and reduces their chance of survival. In another occurrence involving the WascaII, the TSB concluded that the current regulations do not permit or consider the carriage of personal life-saving equipment, which is best suited (based on risk exposure) to provide maximum survival capability for persons in the water.6 The report goes on to highlight the following: The prescriptive nature of the regulations does not provide the necessary flexibility to permit the carriage of personal life-saving equipment that is best suited (based on risk exposure) to provide for a maximum period of survival to persons in the water. A risk-based methodology is used by Transport Canada to address safety deficiencies; however, the regulations in their current form do not yet reflect this reality. A risk-based approach to life-saving equipment standards would give the manufacturer the flexibility to tailor the product to meet the varying needs of the marine sector and provide an acceptable minimum level of safety. The occurrence involving the WascaII follows a fishing fatality in 1999, near Gimli, Manitoba, which was investigated by the TSB (TSB Report M99C0048). Following the occurrence, Transport Canada, in conjunction with other governmental agencies at the federal, provincial, territorial and local levels, worked together with stakeholders (fishers, Aboriginal groups and funding organizations) to improve safety. However, safety concerns with respect to not donning personal life-saving devices, especially during deteriorating weather conditions and emergencies, still persist. Safety Initiatives As part of an ongoing initiative to improve the safety of fishing vessels, the following initiatives are under way: Small Fishing Vessel Safety Manual, which addresses stability, navigation safety and safety on the job, including the dangers of overloading; and Alerting, Detection and Response, a booklet that describes procedures to be followed in alerting the SAR system. Small Fishing Vessel Safety Manual, which addresses stability, navigation safety and safety on the job, including the dangers of overloading; and Alerting, Detection and Response, a booklet that describes procedures to be followed in alerting the SAR system. Communications When the operator of the ShannonDawn made the first of three calls for assistance, he directed authorities only to the ConstanceII on VHF channel11. He did not give a general broadcast on VHF channel16, prefaced by a prescribed urgency designation, that is PANPAN. General emergency broadcasts permit all vessels in the area to be alerted to the emergency and provide an opportunity for a wide range of vessels (and the most appropriate vessel) in the area to respond to the emergency. Furthermore, they provide SAR authorities lead time to prepare to respond to an incident. In this instance, an emergency broadcast could have alerted the larger (17m), more appropriate vessel (the ConstanceI) at an early stage, allowing it to respond to the emergency. When the second VHF radio communication was made by the operator of the ShannonDawn, asking for assistance, the ConstanceII was already some distance from the fishing area and was now limited in its ability to quickly help. The communication again did not attach any sense of urgency. Also, the third and final VHF radio communication from the operator of the ShannonDawn did not indicate urgency. The signal was broken up and difficult to hear, most likely due to the line-of-sight FMVHF signal being blocked between wave crests. These vessels are not fitted with large whip antennas and, consequently, VHF communication signals are broken up or lost in wave heights of4m. The final communication by the ShannonDawn was overheard by the Thunder Bay MCTS Centre/VBA. Because the communication from the ShannonDawn was not prefixed with PANPAN or Mayday, it was not deemed critical by the Thunder Bay MCTS Centre/VBA. Their communication transmission logging equipment, therefore, was not turned on, but they were monitoring the call on VHF channel11. The Thunder Bay MCTS Centre/VBA was formally made aware by the ConstanceII at 1635 one hour after the communication between the ShannonDawn and ConstanceII was cut off that there was a safety urgency in Lake Winnipeg. Given the severe weather and the difficulties encountered when the RachelM's motor did not start, prudence dictates that the Thunder Bay MCTS Centre/VBA ought to have been advised when power was lost aboard the RachelM and, also, immediately when VHFradio contact was lost. However, this was not done. Instances are on record where appropriate authorities have not been notified of an emergency in a timely manner. The escalation of an emergency and the delay in notifying authorities have the potential to compromise the safety of personnel, as well as the vessel itself. Because the success of a SAR mission depends on the prompt and efficient dispatch of SAR resources, it is essential that the authorities be notified as soon as an emergency situation arises. This permits SAR authorities to identify, prepare and dispatch appropriate units and/or emergency equipment in a timely manner should the emergency escalate and/or should SAR assistance be requested or required. Furthermore, early notification permits authorities to better plan the deployment of limited SAR resources during multiple SAR occurrences. Weather The weather can change very rapidly in the Lake Winnipeg region during the summer months. Significant local variances in weather information have been known to take place. There are a limited number of ground monitoring stations through the northern regions of Lake Winnipeg, and Environment Canada is therefore unable to capture some localized weather anomalies. Most fishers rely on the weather forecast prepared and broadcast by Environment Canada and re-broadcast by the Thunder Bay MCTS Centre/VBA on channel26. Weather information on 15June2001 available to the fishers from several sources, either by land telephone or VHF radio channel26, indicated some variance from the actual weather experienced by the fishers for a time period of five to six hours before the occurrence. The prevailing weather within this time frame did not match the broader weather disturbance forecast. Although the fishers had access to information indicating that gale warnings were still in effect, the much calmer prevailing weather in conjunction with the risk profile of the fishers influenced their decision to resume fishing around 1200 and to continue fishing in spite of deteriorating weather conditions. Consequently, when the weather had drastically changed for the worse, there was little or no time left to seek shelter while exposed to the high wind speeds and heavy seas. Vessel Load Condition at the Time of the Occurrence The quantity of fish aboard the RachelM at the time when the ShannonDawn came alongside was estimated to be six tubs. The ShannonDawn's fish load was estimated to have doubled when the fish tubs were transferred from the RachelM, which reduced the receiving vessel's freeboard. Additionally, the freeboard was further reduced by the weight of the two fishers transferred from the RachelM to the ShannonDawn. Given the proximity to land and the shallow depth of water, the seas in the area would be steep. With the vessel deeply laden and with the near-following seas of more than 4m, the vessel would be vulnerable to the action of the waves and shipping seas. As there were no survivors, it could not be determined if any fish tubs were jettisoned from ShannonDawn before the vessel swamped and capsized. Furthermore, the precise sequence of events in the critical stages of the occurrence could not be established. The conclusions are, therefore, derived from a visual examination of the vessel damage and known facts. Swamping/Capsizing Scenario The five to six hours of relative calm within the affected gale-warning weather forecast area resulted in the fishers placing greater emphasis on the milder weather encountered, while downplaying the threat posed by the forecast. The loss of lives can be attributed to the crew not wearing any form of personal life-saving device during the critical stages of vessel operation in inclement weather conditions. Under the prevailing worsening weather conditions, the transfer of fish tubs from the RachelMto the ShannonDawn decreased the freeboard of the ShannonDawn. Also, the shipped seas that were retained on deck created a free-surface effect and significantly reduced the vessel's stability. The ShannonDawn swamped and capsized in heavy seas. Because the bilge pump was not operational, the water shipped over the gunwale was retained on deck to the detriment of the vessel's stability.Findings as to Causes and Contributing Factors The five to six hours of relative calm within the affected gale-warning weather forecast area resulted in the fishers placing greater emphasis on the milder weather encountered, while downplaying the threat posed by the forecast. The loss of lives can be attributed to the crew not wearing any form of personal life-saving device during the critical stages of vessel operation in inclement weather conditions. Under the prevailing worsening weather conditions, the transfer of fish tubs from the RachelMto the ShannonDawn decreased the freeboard of the ShannonDawn. Also, the shipped seas that were retained on deck created a free-surface effect and significantly reduced the vessel's stability. The ShannonDawn swamped and capsized in heavy seas. Because the bilge pump was not operational, the water shipped over the gunwale was retained on deck to the detriment of the vessel's stability. Fishers' traditional attitude is to accept the risks involved in fishing activity. This attitude, coupled with their reluctance to head for shelter, especially in deteriorating weather conditions and when fishing is good, places the crew and vessels at undue risk. Delays in notifying authorities of an emergency, or a developing distress situation, reduces the chances of a successful search and rescue mission and the survival of personnel.Findings as to Risk Fishers' traditional attitude is to accept the risks involved in fishing activity. This attitude, coupled with their reluctance to head for shelter, especially in deteriorating weather conditions and when fishing is good, places the crew and vessels at undue risk. Delays in notifying authorities of an emergency, or a developing distress situation, reduces the chances of a successful search and rescue mission and the survival of personnel. Standard VHF operating procedures for distress and urgency communication were not used, resulting in neither the authorities nor the ConstanceI becoming aware of the situation aboard the ShannonDawn. The outboard motor on the RachelM failed to operate due to an ignition problem in the electronic ignition computer (CDI) unit. A loose ground wire on the CDI was identified as the probable cause.Other Findings Standard VHF operating procedures for distress and urgency communication were not used, resulting in neither the authorities nor the ConstanceI becoming aware of the situation aboard the ShannonDawn. The outboard motor on the RachelM failed to operate due to an ignition problem in the electronic ignition computer (CDI) unit. A loose ground wire on the CDI was identified as the probable cause.